ACORD 133 TN (2005/10)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 07/17/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 133 TN (2005/10)
Tennessee Workers
Compensation Insurance Plan
Assigned Risk Supplement
ACORD 133 TN, Tennessee Workers Compensation Insurance Plan
Assigned Risk Supplement, is used ACORD 130, Workers Compensation Application, to
apply for workers compensation insurance to the Tennessee Workers Compensation
Insurance Plan. For Rating Information and Plan Rules and Factors, go to the
Tennessee Workers Compensation Insurance Plan web site at www.twcip.com.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Applicant Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Proposed Eff Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Telephone Number
Payroll Office Name, Address, and
Enter text: The full name of the location.
IDENTIFICATION SECTION
Enter text: The first address line of the physical location.
IDENTIFICATION SECTION
Enter text: The second address line of the physical location.
IDENTIFICATION SECTION
Enter text: The city of the physical location.
IDENTIFICATION SECTION
Enter code: The state or province of the physical location.
IDENTIFICATION SECTION
Enter code: The postal code of the physical location.
IDENTIFICATION SECTION
Enter number: The primary phone number of the location.
IDENTIFICATION SECTION State Developing Highest Payroll
Enter code: The state which generates the highest payroll. Follow all specific instructions
for this state.
IDENTIFICATION SECTION Year Applicant's Business Began
Enter date: The date the current owners purchased or started the business.
IDENTIFICATION SECTION (checkbox)
1. Do You Lease Workers from a
Labor Contractor? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you lease
employees from a labor contractor?. As used here, if yes, refer to TWCIP instructions.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do you lease
employees from a labor contractor?.
ACORD 133 TN (2005/10)
1 of 8
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Client Company? Yes (checkbox)
2. Do You Lease Workers to a
Check the box (if applicable): Indicates a Yes response to the question, Do you lease
workers to a client company?. As used here, if yes, refer to TWCIP instructions.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do you lease
workers to a client company?.
IDENTIFICATION SECTION Leased Workers? Yes (checkbox)
3. Are You Seeking to Cover the
Check the box (if applicable): Indicates a Yes response to the question, Are you
seeking to cover the leased workers?. As used here, if yes, refer to TWCIP instructions.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Are you seeking
to cover the leased workers?.
IDENTIFICATION SECTION Employers? Yes (checkbox)
4. Do You Provide Temporary
Labor Services to Other
Check the box (if applicable): Indicates a Yes response to the question, Do you provide
temporary labor services to other employers?.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do you provide
temporary labor services to other employers?.
IDENTIFICATION SECTION (checkbox)
5. Do You Have a Franchise or
Licensing Agreement? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you have a
franchise or licensing agreement?. As used here, if yes, provide details of the agreement.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do you have a
franchise or licensing agreement?.
IDENTIFICATION SECTION Apply? Yes (checkbox)
6. Do Trucking Classifications
Check the box (if applicable): Indicates a Yes response to the question, Do trucking
classifications apply?. As used here, if yes, complete questions 11-13.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do trucking
classifications apply?.
IDENTIFICATION SECTION Past Five Years? Yes (checkbox)
7. Has There Been a Name
Change, Consolidation, Merger or
Ownership Change During the
Check the box (if applicable): Indicates a Yes response to the question, Has there been
a name change, consolidation, merger or ownership change during the past five years?.
As used here, if yes, give previous name and date of change. Contact the plan
administrator about an ERM-14.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Has there been
a name change, consolidation, merger or ownership change during the past five years?.
ACORD 133 TN (2005/10)
2 of 8
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Required or Not? Yes (checkbox)
8. Is Applicant Related through
Common Management or
Ownership to Any Entity not Listed
Here, Whether Coverage is
Check the box (if applicable): Indicates a Yes response to the question, Is the applicant
related through common management or ownership to any entity not listed here whether
coverage is required or not?. As used here, if yes, give detailed explanation.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Is the applicant
related through common management or ownership to any entity not listed here whether
coverage is required or not?.
IDENTIFICATION SECTION Enterprises? Yes (checkbox)
9. Is there any Unpaid Workers
Compensation Premium Due or in
Dispute From You or Any
Commonly Managed or Owned
Check the box (if applicable): Indicates a Yes response to the question, Is there any
unpaid workers compensation premium due or in dispute from you or any commonly
managed or owned enterprise?. As used here, if yes, explain including entity name(s)
and policy number(s).
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Is there any
unpaid workers compensation premium due or in dispute from you or any commonly
managed or owned enterprise?.
IDENTIFICATION SECTION In this state? Yes (checkbox)
10. Has there been previous
workers compensation coverage:
Check the box (if applicable): Indicates a Yes response to the question, Has there been
previous workers compensation coverage in this state?.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Has there been
previous workers compensation coverage in this state?.
IDENTIFICATION SECTION other state? Yes (checkbox)
Has there been previous workers
compensation coverage: In any
Check the box (if applicable): Indicates a Yes response to the question, Has there been
previous workers compensation coverage in any other state?.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Has there been
previous workers compensation coverage in any other state?.
IDENTIFICATION SECTION Business (checkbox)
If No, was this due to: New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy. As used here, indicates there was no previous workers compensation
insurance because this is a new business policy.
IDENTIFICATION SECTION Self-Insured-Indep (checkbox)
Check the box (if applicable): Indicates if the insured is independently self-insured.
IDENTIFICATION SECTION Self-Insured-Group (checkbox)
Check the box (if applicable): Indicates if the insured is self-insured as part of a group.
ACORD 133 TN (2005/10)
3 of 8
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION # Employees (checkbox)
Check the box (if applicable): Indicates there was no previous coverage due to the
number of employees.
IDENTIFICATION SECTION Yes (checkbox)
11. Do You or Your Employees
Regularly Operate from a Base
Terminal Which is Used to Load,
Unload, Store or Transfer Freight?
Check the box (if applicable): Indicates a Yes response to the question, Do you or your
employees regularly operate from a base terminal(s) which is (are) used to load, unload,
store or transfer freight?. As used here, if yes, provide a list of terminal addresses.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Do you or your
employees regularly operate from a base terminal(s) which is (are) used to load, unload,
store or transfer freight?.
IDENTIFICATION SECTION Terminal Addresses: Street One
Enter text: The first address line of the physical location. As used here, this is the location
of a base terminal address.
IDENTIFICATION SECTION City One
Enter text: The city of the physical location. As used here, this is the location of a base
terminal address.
IDENTIFICATION SECTION County One
Enter text: The county of the location. As used here, this is the location of a base terminal
address.
IDENTIFICATION SECTION ST One
Enter code: The state or province of the physical location. As used here, this is the
location of a base terminal address.
IDENTIFICATION SECTION Zip Code One
Enter code: The postal code of the physical location. As used here, this is the location of a
base terminal address.
IDENTIFICATION SECTION Street Two
Enter text: The first address line of the physical location. As used here, this is the location
of a base terminal address.
IDENTIFICATION SECTION City Two
Enter text: The city of the physical location. As used here, this is the location of a base
terminal address.
IDENTIFICATION SECTION County Two
Enter text: The county of the location. As used here, this is the location of a base terminal
address.
IDENTIFICATION SECTION ST Two
Enter code: The state or province of the physical location. As used here, this is the
location of a base terminal address.
IDENTIFICATION SECTION Zip Code Two
Enter code: The postal code of the physical location. As used here, this is the location of a
base terminal address.
IDENTIFICATION SECTION Street Three
Enter text: The first address line of the physical location. As used here, this is the location
of a base terminal address.
IDENTIFICATION SECTION City Three
Enter text: The city of the physical location. As used here, this is the location of a base
terminal address.
IDENTIFICATION SECTION County Three
Enter text: The county of the location. As used here, this is the location of a base terminal
address.
ACORD 133 TN (2005/10)
4 of 8
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION ST Three
Enter code: The state or province of the physical location. As used here, this is the
location of a base terminal address.
IDENTIFICATION SECTION Zip Code Three
Enter code: The postal code of the physical location. As used here, this is the location of a
base terminal address.
IDENTIFICATION SECTION Records or Logs? Yes (checkbox)
12. Can Each Driver's State of
Majority Driving Time be
Established Through Verifiable
Check the box (if applicable): Indicates a Yes response to the question, Do you or your
employees regularly operate from Can each driver's state of majority driving time be
established through verifiable records or logs?.
IDENTIFICATION SECTION No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Can each
driver's state of majority driving time be established through verifiable records or logs?.
IDENTIFICATION SECTION Residence: 1 Driver Name One
Please Provide a List of all
Drivers/Helpers And Their State of
Enter text: The driver's full name.
IDENTIFICATION SECTION Terminal # (See Above) One
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Majority Driving State One
Enter code: The state or province where the driver does the majority of their driving.
IDENTIFICATION SECTION Residence State One
Enter code: The state or province of the driver. As used here, this is the driver's state of
residence.
IDENTIFICATION SECTION Driver Name Two
Enter text: The driver's full name.
IDENTIFICATION SECTION Terminal # Two
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Majority Driving State Two
Enter code: The state or province where the driver does the majority of their driving. As
used here, this is the driver's state of residence.
IDENTIFICATION SECTION Residence State Two
Enter code: The state or province of the driver.
IDENTIFICATION SECTION Driver Name Three
Enter text: The driver's full name.
IDENTIFICATION SECTION Terminal # Three
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Majority Driving State Three
Enter code: The state or province where the driver does the majority of their driving. As
used here, this is the driver's state of residence.
ACORD 133 TN (2005/10)
5 of 8
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Residence State Three
Enter code: The state or province of the driver.
INSURANCE COMPANIES
1. Have You Received any Offers
of Voluntary Coverage? Yes
(checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Have you
received any offers of voluntary coverage?.
INSURANCE COMPANIES
No (checkbox)
Check the box (if applicable): Indicates a No response to the question, Have you
received any offers of voluntary coverage?.
INSURANCE COMPANIES
2. Indicate the Number of
Insurance Companies Which Have
Refused the Applicant Coverage in
the Last 60 Days.
Enter number: The number of insurance companies that have refused the applicant
coverage in the past specified time. As used here, this is the number of insurance
companies that have refused coverage in the last 60 days (or in accordance with state
specific guidelines). Tennessee requires two (2) or more.
INSURANCE COMPANIES
The insured elects to be excluded
from the list of employers in the
assigned risk plan: Yes
(checkbox)
Check the box (if applicable): Indicates the employer has elected to be excluded from the
list of employers in the assigned risk plan.
INSURANCE COMPANIES
No (checkbox)
Check the box (if applicable): Indicates the employer has elected to be included in the list
of employers in the assigned risk plan.
REMARKS
Remarks
Enter text: The remarks associated with the Workers Compensation line of business.
PREMIUM PAYMENT
Payment Method Check # One
Enter number: The first digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Two
Enter number: The second digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Three
Enter number: The third digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Four
Enter number: The fourth digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Five
Enter number: The fifth digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Six
Enter number: The sixth digit of the check number.
PREMIUM PAYMENT
Payment Method Check # Seven
Enter number: The seventh digit of the check number.
PREMIUM PAYMENT
Premium Payment Amount One
Enter number: The millions digit of the premium amount.
PREMIUM PAYMENT
Premium Payment Amount Two
Enter number: The hundred thousands digit of the premium amount.
PREMIUM PAYMENT
Premium Payment Amount Three
Enter number: The ten thousands digit of the premium amount.
PREMIUM PAYMENT
Premium Payment Amount Four
Enter number: The thousands digit of the premium amount.
PREMIUM PAYMENT
Premium Payment Amount Five
Enter number: The hundreds digit of the premium amount.
PREMIUM PAYMENT
Premium Payment Amount Six
Enter number: The tens digit of the premium amount.
ACORD 133 TN (2005/10)
6 of 8
Section Name
Field Name
Field and/or Section Description
PREMIUM PAYMENT
Premium Payment Amount Seven
Enter number: The ones digit of the premium amount.
PREMIUM PAYMENT
Is the Premium Financed? Yes
Check the box (if applicable): Indicates the premium has been financed.
PREMIUM PAYMENT
No (checkbox)
Check the box (if applicable): Indicates the premium has not been financed.
PREMIUM PAYMENT
If Yes List Finance Company
Enter text: The name of the company financing the premium, if applicable.
APPLICANT'S STATEMENT Applicant's Statement
Enter text: The description of any difficulties the applicant has had with any producer or
company in regard to handling of any claim or accident report.
APPLICANT'S STATEMENT Applicant's Name and Title
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT'S STATEMENT
Enter text: The title of the individual in the organization or his relationship to the
organization.
APPLICANT'S STATEMENT Date
Enter date: The date the form was signed by the named insured.
APPLICANT'S STATEMENT Officer)
Signature (Must be an Owner or an
Sign here: Accommodates the signature of the applicant or named insured.
PRODUCER'S
CERTIFICATION
Agency Fein
Enter identifier: The producer's tax identification number. This may be the federal
employer identification number or social security number.
PRODUCER'S
CERTIFICATION
Agency Phone Number
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
PRODUCER'S
CERTIFICATION
Agency Fax Number
Enter number: The fax number of the producer/agency.
PRODUCER'S
CERTIFICATION
Resident License Number
Enter identifier: The State License Number of the producer.
PRODUCER'S
CERTIFICATION
Expiration Date
Enter date: The date the producer's state license expires.
PRODUCER'S
CERTIFICATION
Non-Resident License Number
Enter identifier: The producer's non-resident license number.
PRODUCER'S
CERTIFICATION
Expiration Date
Enter date: The date the producer's non-resident license expires.
PRODUCER'S
CERTIFICATION
Producer Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
PRODUCER'S
CERTIFICATION
Date
Enter date: The date the producer signed the form.
PRODUCER'S
CERTIFICATION
Producer Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
ACORD 133 TN (2005/10)
7 of 8
Section Name
Field Name
Field and/or Section Description
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 133 TN (2005/10)
8 of 8